Guide to completing the patient medication information

Version 1 May 2018

Guide to completing Patient Medication Information Background

An essential component of managing people with persistent pain is the multidisciplinary team, which may include, but is not limited to, exercise physiologists, medical doctors and specialists, nurses, occupational therapists, physiotherapists, psychiatrists, psychologists and social workers. Working closely with the multidisciplinary team are the administration staff, and together they complete the picture of the multidisciplinary pain service and can facilitate the effective delivery of services to people with persistent pain. Naturally, this diverse group of people involved with the delivery of care to people with persistent pain will have differing levels of knowledge when it comes to the medications that patients may be taking. This guide, combined with a specifically developed tool, will assist staff at pain services to record medication information in the ‘Office Use Only’ section in epiCentre. Collecting patient medication information can enable improved assessment and management of a patient’s medication use throughout their episode of care. Medication information collected The variables recorded and questions asked relating to a patient’s medication use are:

• Medicine name and strength • The patient’s daily intake of the medicine and how many days a week they require it • The ‘types’ of drug groups taken (Note: this list only includes medications belonging to drug groups

identified as being of particular importance in the management of chronic pain): o Opioids o Paracetamol o Non-steroidal anti-inflammatory drugs (NSAIDs) o Medicinal cannabinoids o Antidepressants o Anticonvulsants o Benzodiazepines

• If the patient is talking an opioid, the daily oral morphine equivalent (oMEDD) in milligrams (mg) is recorded

• If the patient is taking an opioid, is it required more than 2 days per week? • Is the patient on an opioid replacement/substitution program?

How medication information is reported by ePPOC Your hard work entering patient medication information data is acknowledged by its inclusion in your bi-annual Patient Outcomes in Pain Management reports in the following areas, for use in ongoing quality improvement in patient care. Opioid Use Benchmark

Opioid Use Benchmark graph

Medication use at referral

Change from referral to episode end

Change from referral to post episode follow-up

Opioid Use Indicator

Entering medication information in epiCentre If a patient completes a paper version of their questionnaire, you will need to manually enter their medication information. To do this you will need to access the corresponding questionnaire in epiCentre. If this is new to you then you can follow these simple steps below or refer to the epiCentre Quick Training Manual:

• In epiCentre, on the PATIENTS page you will need double click on the patient’s name who requires data entry from a paper questionnaire.

• This takes you to the Individual Patient page, at the top right on that page you will find a button called Browse Questionnaires, click it once, this opens up the individual patient’s questionnaire page.

• On the Individual Patients Questionnaire page, double click on the line of the questionnaire where you need to enter the data.

• This opens the Questionnaire Manager pop-up window (see picture below), click on OFFLINE button (circled), this opens up the questionnaire for completion by you. You will note a series of 10 tabs across the top that match the paper questionnaire headings. Medication Use is one of those headings – this is where you will enter the medication data. You will also see one final tab, ‘Office Use Only’, the remainder of this guide will also assist you to complete information within that section.

If patient has completed the questionnaire online, the medications they listed will automatically appear under the ‘Medication Use’ tab. Either way, once the ‘Medication use’ section is completed, the ‘Office Use Only’ section is automatically populated with the medications listed (see Aaron’s example below).

Aaron’s Medication use section

Aaron’s Office Use Only section

When the patient has reported taking medications… The first item to complete in the Office Use Only section is whether or not the patient is taking medications. This item is based on whether or not the patient reports medications in the ePPOC questionnaire. The response to this item is not based on the referral letter or any other source. It is for patient-reported medications; therefore, if the patient did not report any select ‘No’ as noted above. If in doubt check with the patient. If the patient did report medications then you need to open up more options to enter further patient medication information in the ‘Office Use Only’ tab. You do this by selecting ‘Yes’ in the ‘Did patient report medications?’ box from the drop down menu.

When you do this, it opens up seven steps for you to complete, these are detailed in the following section. The steps required to complete all patient medication information This next section will take you through the seven remaining steps required to enter all patient medication information items and complete the ‘Office Use Only’ section.

Step 1 – ‘Possible inaccuracies in medication reported’

This step allows pain management staff to highlight possible inconsistencies in the patient-reported medication information compared to information received from another source. For example, the patient may have reported that they are not taking medications yet a doctor’s referral letter may indicate otherwise. Regardless of any inconsistency, the medication information entered into epiCentre should be based on the patient report. Select ‘No’, unless indicated otherwise (if in doubt consult a senior staff member).

Now move on to Steps 2 & 3 – you will learn a lot in these steps…

Step 2 – ‘Tick all drug groups taken’

This step asks you to record each of the drug groups that are taken by the patient. The seven drug groups listed in epiCentre have been determined as medications of particular interest in pain management by the Faculty of Pain Medicine (FPM). These groups include;

• Opioids • Paracetamol • Non-steroidal anti-inflammatory drugs (NSAIDs) • Medicinal Cannabinoids • Antidepressants • Anticonvulsants • Benzodiazepines

Of course, patients may also be taking other medications, for example, for high blood pressure, cholesterol and/or diabetes. As those types of medications are not one of the drug type identified by the Faculty, they do not require reporting in this section. The other important thing to note is where you discover patients are taking more than one medication in the same drug group you only need to tick that box once. Don’t worry if you do not know which drug group medications belong to, as we have created the ePPOC Drug Group Tool to help you identify them. Before we get to the tool, the following section will provide a little information about each of the seven drug groups and why they are important in pain management. A little information about the seven drugs groups of current focus in pain management

• Opioids – are natural or synthetic chemicals that are similar to morphine, originally derived from the opium poppy. Opioids are widely used for moderate to severe pain relief and may be used in combination with other medications for added pain relief, for example, paracetamol, non-steroidal anti-inflammatory drugs [NSAIDs], antidepressants and anticonvulsants.

• Paracetamol – is an over-the-counter medication used for mild to moderate pain, it can also reduce fever, and it is often combined with other medications (opioids and NSAIDs) for added pain relief.

• NSAIDs – are a group of medications used for pain relief particularly for pain caused by inflammation. They can also reduce fever and may be combined with other medications (opioids and paracetamol) for added pain relief.

• Antidepressants – are a group of medications used to treat a range of mental disorders including

depression and anxiety, which can be common in people with chronic pain. Certain types of antidepressants have also proven beneficial for treating chronic pain.

• Anticonvulsants – also known as anti-epilepsy/anti-seizure medications are used to treat a range of central nervous system disorders including epilepsy. Some have also proven beneficial for treating chronic pain, particularly nerve (neuropathic) pain.

• Benzodiazepines – also known as ‘benzos’, are a group of medications called minor tranquillisers. They can help people with anxiety or sleep problems and therefore may be used by some people with chronic pain. A group of similar drugs called Z Drugs are also included in this category.

• Cannabinoids – these are the active components within the cannabis plant. There are over 100 cannabinoids in cannabis, cannabidiol (CBD) is one that is commonly used in medicinal cannabis. CBD is non-psychoactive and may be effective for a number of conditions including chronic pain.

Aaron’s list

Here in Aaron’s example (below) you can see he has reported eight different medications - now let’s learn a little about the ePPOC Drug Group Tool and use it to help you complete this item and other medication information items in epiCentre.

1. Panadol osteo 2. Tramal 3. Lyrica 4. Tofranil 5. Voltaren 6. Metformin 7. Crestor 8. Fish oil

The ePPOC Drug Group Tool – 6 tips To complete Step 2 ‘Tick all drug groups taken’, a specific spreadsheet and PDF (either can be used) were created to assist you to identify the drug group a medication belongs to. It is also useful for the completion of other items, highlighted later. This spreadsheet works like any other excel spreadsheet (PDF is in alphabetical order), allowing you to sort the cells and use the search tool. It contains the following features/functions: 1. It has 4 headings at the top including (see below):

a. Medication names b. Drug Group (also for use later) c. Opioid Type (for use later) d. Route* (for use later)

*A little information about the ‘Route’: this describes the way medications enter the body, this information is required for later steps. The most common routes of medication administration include:

• Oral – taken by mouth • Sublingual – placed under the tongue to absorb • Transdermal – usually patches that allow the medication to absorb through the skin • Parenteral – this includes injected medications • Intrathecal – medication that is administered directly into the spinal cord space • Other – suppository – rectal, buccal – placed in at the side of the cheek (much like sublingual),

intranasal – sprayed into the nostrils

2. At the base of the tool, you will see there is one sheet titled ALL Drug groups, (see below). This sheet has attempted to list ALL current medications of focus (AUS & NZ) in pain management in one table. Using the search tool in excel you can search for any drug from this sheet. There are currently around 386 medications listed.

3. When searching for a medication you may receive this error message.

This may be due to the following reasons:

a. A spelling error when typing into the search tool (check spelling, including the patients spelling. NB: you don’t have to enter the entire word to search).

b. The drug the patient listed may not be a medication of focus (one of the seven drug groups); therefore, it will not be included. For example, the medication may be for diabetes or high blood pressure – if in doubt ask a senior staff member or email us at eppoc@uow.edu.au.

c. Whilst we have sought to include all possible medications of focus in the ePPOC Drug Group Tool, there may be a new medication or we may have missed one, therefore please don’t hesitate to contact us and let us know.

Note: We will be updating the ePPOC Drug Group Tool as required - the most current version will be available on the ePPOC website for you to download.

4. Medications beginning with a capital letter indicate it is the brand name for that medication, those without

a capital are the generic name, for example ‘Disprin’ and ‘aspirin’ – these are the same medication, one is a brand name ‘Disprin’ and the other is the generic name of the drug.

5. You will see some medications will have two drug groups listed. For example, Panadeine contains both paracetamol and codeine, which includes these two drug groups: Paracetamol and an Opioid.

6. Finally, the ePPOC Drug Group Tool has a key at the base in RED explaining some symbols used:

a. ^ is the symbol next to all generic medicine names (Brand names start with a capital letter – only generic names are used in the oMEDD – described next section)

b. * is next to medications where the ‘Route’ can vary (check with patient or appropriate staff member if unsure)

c. # is next to all combination medications that also contain an opioid (reminds us to only enter the mg of opioid [e.g. codeine or tramadol] into the oMEDD – described in the next section)

d. N/A is in any column that is not applicable for use with the oMEDD – (described next section).

Searching within the ePPOC Drug Group Tool Excel spreadsheets have a tool on the right hand side (magnifying glass icon) called ‘Find & Select’. Click on ‘Find’ or you can press ‘Control + F’ on the keyboard to open up the ‘Find & Replace’ window (next page). Here you can type in the medication the patient has reported (exact name or part of it) and click ‘Find Next’ – if it is there it will be highlighted within the spreadsheet with the ‘Drug Group’ it belongs to and other details on the same line (see example search next page).

You can also search alphabetically in excel by right clicking on the heading ‘Medication names (ALL)’, and select sort A-Z. Please note the excel column is pre-sorted from A-Z, the PDF version is also sorted A-Z. In addition, this tool is available as a PDF in alphabetical order so you could print a hard copy to keep at your desk if multiple screens are an issue.

For example, a search for the drug called ‘Ordine’ should look like this…

Using the ePPOC Drug Group Tool to identify drug groups of focus in pain management

Now go to the ePPOC Drug Group Tool spreadsheet or use the PDF printed hard copy. To complete Step 2 we need to identify the drug groups that Aaron is taking so we can tick them off in the relevant section. The ePPOC Drug Group Tool will also provide answers to use when completing Step 3.

Results: • You should have discovered that Aaron is taking five of the seven drug group’s paracetamol, an opioid,

an anticonvulsant, an antidepressant and a NSAID. • You would not have found three of the medications listed (Metformin, Crestor, and Fish oil). This is because

two are medications for diabetes and cholesterol and one is a supplement (they are not in the tool because they are not medications of focus in pain management).

• NB For use with Step 3 - o For each medication that is an opioid, you must take note of the following: ‘Dose’ (mg or mcg, how many taken per day, how many days taken per week) ‘Opioid Type’ ‘Route’

o In Aaron’s example he is taking one opioid therefore you should note the following: Dose – Tramal 100mg x 2 taken every day Type – tramadol Route – oral

Now you can complete Step 2 – ‘Tick all drug groups taken’ • You will now be able to ‘Tick all drug groups taken’ to complete Step 2. In this case, Aaron was taking

medications from five of the drug groups; o Paracetamol o an opioid o an anticonvulsant o an antidepressant and, o a NSAID.

• Tick them off (as shown below) and move on to Step 3.

Step 3 – ‘Daily oral morphine equivalent in mg’ (oMEDD)

To discover Aaron’s oMEDD you will need to use the oMEDD conversion tool provided by ePPOC – the following section describes the background and why we need to use it, and the components of the ‘ePPOC oMEDD conversion tool – weekly use’; First, a little background about the tool and why we use it. • The conversion tool is based on the oral morphine equivalent daily dose (oMEDD), which was developed by

the Faculty of Pain Medicine Australian and New Zealand College of Anaesthetists1 to assist us to calculate a total daily equivalent of morphine as a comparison. This is particularly useful when patients are taking a range of different opioids. The only Drug Group out of the seven that is relevant for use with the oMEDD is opioids.

• Opioids can have harmful side effects, therefore the Australian and New Zealand governments, Pain Societies and pain management services will generally seek to reduce the use of opioids where possible. The oMEDD is useful to calculate the total amount in order to make targets for reduction and is helpful when patients take a number of different types of opioid medications. A reduction of a patient’s oMEDD by 50% from referral to episode end is now an Australasian benchmark in ePPOC.

Reference1: http://www.opioidcalculator.com.au/ The ‘ePPOC oMEDD Conversion Tool – weekly use’ components; You will note the following (see example below): • It is an excel spreadsheet that has been created to automatically calculate a patient’s oMEDD once certain

information has been entered into it. • It has several headings across the top – including, Current opioids, Units, Medicine Strength, How many taken

per day, Days used per week, Conversion factor, oMEDD, Examples of medications • The YELLOW columns are where you enter the information: medicine strength, how many are taken per day,

number of days taken per week and in the last yellow column you will see the results of the oMEDD calculation. o The Medicine Strength column is where you enter dose per unit information then tab or press enter,

for e.g. oxycodone 5mg – enter the number 5. o The How many taken per day column is where you enter the number of tablets taken each day, for e.g.

if the patient states they take six each day then enter the number 6.

o The Days used per week column records the number of days a patient uses the opioid over a week – mostly it will be seven days, however sometimes people use opioids for breakthrough pain which may only be once per week.

o The ‘oMEDD’ column will then display the ‘oral morphine equivalent daily dose’, which has been automatically calculated and will calculate to a total ‘oMEDD’ value (DISPLAYED AT THE BOTTOM) when all opioids have been added.

• The grey headings down the left hand side describe the ‘Routes’ of administration (discussed earlier). As you

can see, for example, codeine, morphine and fentanyl are listed more than once, which is why the Route is important to know so values can be entered into the correct place.

• Most medication ‘Units’ are in milligrams (mg), so all you need to do is enter the single tablet dosage, the number of tablets they take each day, and days taken per week and the result (oMEDD) will be automatically calculated for you.

• If the medication is a transdermal patch the number that needs to be entered is in micrograms (mcg). This is because the medication is delivered through the skin slowly at an hourly rate all day. There are other less common medications that are also in mcg. Just remember these values are in RED to highlight that they are a little different.

• To record transdermal patches and/or infusion pump medications that are delivered slowly over the day, every day, enter the Medication strength e.g. for a 5 mcg patch just enter 5, for How many taken per day enter 1 and for Days used per week enter 7. Similarly, for example, if the patient is receiving a 10mg hydromorphone subcutaneous infusion pump with medication delivered slowly over 24 hours every day, then you would enter 10 in strength, 1 in how many per day and 7 in days per week. Now with the opioid information you noted down before let’s enter Aaron’s information.

Entering Aaron’s opioid medication (Tramal) into the oMEDD:

• We took note earlier when we used the ‘ePPOC Drug Group Tool’ that Aaron was taking an opioid We also noted the following:

o ‘Dose’ – The dose of this opioid was 100mg and he takes 2 each day of the week o ‘Type’ – tramadol o ‘Route’ – of administration is oral.

• From the medication list in epiCentre, we know the daily dosage as he takes 100mg x 2 every day (7 days/week).

o With the oMEDD open (see below), you can see where the dosage values can be entered (medicine strength), how many are taken per day and how many days they are taken each week. Once all values for all opioid medications are entered, the automatic calculation is done by simply pressed ‘Enter or Tab’. Only the TOTAL AVERAGE oMEDD (mg) calculation displayed at the bottom needs to be entered into epiCentre.

This is how it will look in the Conversion Tool:

Now you can complete Step 3 You can now enter Aaron’s TOTAL oMEDD (see below) as the number only (40), as epiCentre will only accept numbers in this field; if you type mg, you will receive an error message.

Now move on to Steps 4 – 7, these steps are easy…

Important TIPS relating to patient reports of medications: • If patients give a range of days that they take a medication (e.g. 2-3 or 3-4 days per

week), choose the maximum days • If patients state ‘PRN’ or ‘As required’ then record the medication as if they are taking it

every day and consult with the patient to record the correct dose where possible. You may also tick the checkbox in epiCentre to indicate a possible inaccuracy in the patient’s report of medication use – Step 1 in this guide.

Step 4 – ‘Opioid medication > 2 days/week?’

Using Aaron’s example, we took note of any opioids he listed. We know that he is taking Tramal, which is an opioid; he also stated he is taking two tablets every day so we know that he is taking it on more than 2 days per week. Select Yes for this example and move on to Step 5. Step 5 – ‘Opioid replacement/substitution program’

Information related to this item may have been provided in referral documentation or by the patient. Patients may be on an opioid replacement/substitution program as an approach to managing opioid addiction (a harmful side effect of opioids). They may be taking medications that include methadone, naltrexone and buprenorphine as part of their replacement/substitution program. Select No unless this is specified in the referral letter or by the patient and move on to Step 6.

40

Step 6 – ‘Is this section complete?’

Only select ‘Yes’ if all items have been completed, then move to Step 7. If all items have not yet been completed, for example, if you need to leave this to attend to other work matters then ensure you enter No before moving on to Step 7. You will then be able to return to your saved work and finish the section later. Step 7 – ‘Submit’

You must always click on ‘Submit’ to save your information. This will either mark the section as complete (if you answered Yes in Step 6) or allows you to return later to your saved changes to complete the section. If marked as complete the status of the questionnaire in epiCentre will change from light green to dark green on the ‘Questionnaires’ page in epiCentre (example below), This makes it easier to identify questionnaires that require completion.

Note: If you hover your mouse over any of the colours in the questionnaires page in epiCentre, you will get a ‘tip’ that describes what the colour means. If you want to discard any changes you made, click on ‘Cancel’ and the questionnaire will close without saving any of your work.

What if Aaron didn’t report any medications? If the patient did not report any medications, you have four tasks to complete the ‘Office Use Only’ section:

• Did the patient report medications? If medications have been listed, the answer is Yes otherwise… o Select NO

• Possible inaccuracies in medication reported? (see previous notes on this for Step 1) • Is this section complete?

o Select YES (if completed) or NO (if you need to return later) • SUBMIT

o Click submit to ensure that you save any changes you have made

Note: As mentioned previously, whilst this is the ‘patient reported’ medication list, if you think the patient is taking medications (for example, medications were listed in a referral letter) and they have either not completed/or had difficulty completing the section, ensure that you consult with the patient or a relevant staff member before moving on. Complete the exercises in the next section to test your new skills and knowledge and your understanding of the patient medication information section (Office Use Only) in epiCentre.

If after completing this self-guided learning package you feel like you have more questions or require further training/information please don’t hesitate to contact us at eppoc@uow.edu.au or call +612 4221 5058.

Exercises for testing knowledge/skills: Using the ePPOC Drug Group Tool and the Conversion Tool, for each of the exercises below identify the following to complete the ‘office use only’ section in epiCentre: (Answers are included at the end).

1) The drug groups types taken – using the ePPOC Drug group Tool 2) The total oMEDD (mg) value – using the ePPOC oMEDD Conversion Tool – Weekly use 3) Whether the opioid medication is taken more than 2 days/week – using patient report

1. John reports taking the following medications:

Medicine name Medicine strength Daily intake Gabalex 100mg 1/day (7 days per week) Endep 50mg 1/day (7 days per week) Panadeine Forte 500mg paracetamol/30mg codeine 6/day (2 days per week) Oxycontin 50mg 2/day (7 days per week)

2. Marj reports taking the following medications:

Medicine name Medicine strength Daily intake Naprosyn 750mg 1/day (7 days per week) Parapane 500mg 8/day (7 days per week) Jurnista 10mg 2/day (7 days per week) Cipramil 25mg 1/day (7 days per week) Gapentin 50mg 2/day (7 days per week) Alepam 10mg 1/day (7 days per week) Lipitor 75mg 1/day (7 days per week) Diamicron 60mg 2/day (7 days per week)

3. Alex reports taking the following medications:

Medicine name Medicine strength Daily intake Endone 5mg 2/day (3 days per week) Panadeine extra 500mg paracetamol/15mg codeine 8/day (7 days per week) Meloxicam 50mg 2/day (7 days per week) Epilim 100mg 1/day (7 days per week)

4. Suzie reports taking the following medications:

Medicine name Medicine strength Daily intake Norspan 5mcg/hr 1/day (7 days per week) Nuramol 200mg ibuprofen/500mg paracetamol 6/day (7 days per week) Lexam 25mg 1/day (7 days per week) Temaze 5mg 1/day (7 days per week)

5. Chris reports taking the following medications:

Medicine name Medicine strength Daily intake Doloxene 50mg 4/day (7 days per week) Oxycodone 5mg 4/day (3-4 days per week) Pregaredi 50mg 2/day (7 days per week) Lexapro 25mg 1/day (7 days per week)

Answers: 1. John

Types of drug groups Total oMEDD Opioids > 2days/week

Tick 4/7 drug groups – (Anticonvulsant, Antidepressant, Opioid & Paracetamol) Note: Only enter the codeine value from Panadeine Forte.

157mg (NB remember enter numerals only & Johns Panadeine Forte was taken only 2 days per week

Yes

2. Marj

Types of drug groups Total oMEDD Opioids > 2days/week

Tick 6/7 drug groups – (NSAID, Paracetamol, Opioid, Anticonvulsant, Antidepressant & Benzodiazepine) Note: Lipitor + Diamicron will not be in the ePPOC Drug Group Tool

100mg Yes

3. Alex

Types of drug groups Total oMEDD Opioids > 2days/week

Tick 4/7 drug groups – (Opioid, Paracetamol, NSAID & Anticonvulsant) Note: Only enter the codeine value from Panadeine extra.

22mg (NB Alex only takes Endone on 3 days per week)

Yes

4. Suzie

Types of drug groups Total oMEDD Opioids > 2days/week

Tick 5/7 drug groups – (Opioid, NSAID, Paracetamol, Antidepressant & Benzodiazepine) Note: This opioid is a transdermal patch, the dose is in mcg/hour and Nuramol contains 2 drug groups.

10mg (NB remember a transdermal patch is entered as 1/day and 7 days/week in the oMEDD Conversion Tool)

Yes

5. Chris

Types of drug groups Total oMEDD Opioids > 2days/week

Tick 3 of the 7 drug groups – (Opioid, Anticonvulsant, Antidepressant) Note: The opioid type for Doloxene is dextropropoxyphene.

37mg (NB Chris reported taking oxycodone 3-4 days per week – therefore choose the Maximum days)

Yes